1. 4GuardianReleaseUNL2002.doc
Guardian Form (Youth)
University of Nebraska
Campus Recreation
WAIVER AND RELEASE OF LIABILITY for Campus Recreation Activities
DISCLAIMER: The UNIVERSITY OF NEBRASKA is NOT RESPONSIBLE for any injury or loss of
property to any person suffered while warming up, practicing, traveling, playing, or participating in Campus
Recreation Activities for any reason whatsoever, including ordinary negligence.
This WAIVER and RELEASE OF LIABILITY was executed this ____ day of ___________ 2___, at Lincoln,
Lancaster County, State of Nebraska by __________________, (Guardian) as Guardian of
(referred to in this document as Minor) in favor of the UNIVERSITY OF NEBRASKA and its Regents,
Officers, Employees, Instructors, Staff, agents, operators, successors, and assigns (UNIVERSITY).
In consideration for the Minor’s participation in Campus Recreation Activities, Releasor hereby RELEASES and
covenants not-to-sue the UNIVERSITY for any and all present and future claims resulting from ordinary
negligence on the part of the UNIVERSITY for property damage, personal injury, or wrongful death arising as a
result of engaging in, using University facilities and equipment, or receiving instruction for Campus Recreation
Activities or activities thereto, wherever, whenever, or however the same may occur. Releasor hereby voluntarily
waives any and all claims or actions resulting from ordinary negligence, both present and future, that may be made
by Releasor’s family, estate, personal representative, heirs, or assigns.
Further, Releasor realizes that participation in Campus Recreation Activities involves certain risks and danger and
is a vigorous activity involving severe respiratory and cardiovascular stress. Releasor has hereby been made aware
that participation in Campus Recreation Activities has the following non-exclusive list of certain risks which I
accept: death; head, eye, neck, and spinal injury resulting in complete or partial paralysis; brain damage; heart
attack; blisters; cuts; lacerations; abrasions; concussions; contusions; strains; sprains; dislocations; fractures; cold
and heat injuries; water immersion; drowning; lightning strikes; injury to bones, joints, muscles, internal organs; and
environmental conditions. In addition, I understand and accept the incidental risks of travel to and from the site of
activity; participation at sites that may be remote from available medical assistance; and the possible reckless
conduct of other participants.
In the event of a medical emergency, the University of Nebraska or its representatives have my permission to take
whatever measures they deem reasonable to render assistance and that I and/or my family will be financially
responsible for any expense involved.
I have read and understand that this WAIVER is intended to be as broad and inclusive as permitted by the laws of
the State of Nebraska and agree that if any part is held invalid, the remaining parts of this WAIVER AND
RELEASE will continue in full force and effect as intended. I further agree that the venue for any legal proceeding
shall be in the State of Nebraska.
______________ ___________________ __________ __________________ ______________
GUARDIAN (Signed) (Printed) Date
_______________ ________ _______________
Minor’s Name Minor’s Date of Birth
Medical-Insurance Information and Consent
As Guardian of ______________________, he/she is physically capable of participating in all Campus Recreation
Activities under normal, reasonable conditions and medical/health insurance coverage for the minor child is the
Guardian’s responsibility.
Medical Insurance Co:____________________ Policy# __________________________